Student Acceptable Use & Internet Safety Policy

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Student Acceptable Use & Internet Safety Policy Powered By Docstoc
					                                                                                                                                                                       777 Aileen Street ● Camarillo, CA 93010 ● (805) 384-1415 Fax: (805) 384-1473

                                                                                         Camarillo Academy of Progressive Education (CAPE)
IMPORTANT: Driver is required to complete all statements below prior to trip and must produce evidence of current auto insurance to the
office at the time of applying. Original form is maintained in school office.

1.          Name of your student you are volunteer driving for:______________________________ your student’s teacher:____________________
            Name of your student you are volunteer driving for:______________________________ your student’s teacher:____________________
            Name of your student you are volunteer driving for:______________________________ your student’s teacher:____________________

2.          Driver’s Name __________________________________________________________________________________________________

3.          Home Address __________________________________________________________________________________________________

4.          California Driver’s License No. ________________________________________________ License Expiration Date _________________

5.          Year and make of car _______________________________________________________ Car License No. _______________________

6.          Does the vehicle have any known mechanical or safety deficiencies? Yes No                                                                                                                                □ □
            If yes, what are they? ___________________________________________________________________________________________

7.          Have you had a moving violation and/or accident within the past year?                                                                                                                              Yes       □ No□
8.          Do you have any physical condition or are you taking medication which would affect driving safety?                                                                                                                                                                            Yes        □ No□
9.          Are you 18 years old or older?                                                             Yes       □ No□
10. Seating Capacity of Vehicle _______ Does your vehicle have one set of working seatbelts per occupant? Yes                                                                                                                                                                                                        □ No□
11. Registered Owner’s Name/Address _______________________________________________________________________________

12. Name of liability insurance company _______________________________________________________________________ None ( )

13. Insurance Co. Address ________________________________________________ Phone No.________________________________

14. Policy No. ________________________________________________________ Insurance Expiration Date_______________________

15. Liability Insurance Limits :
      Bodily Injury: (Combined single Limit $_____________)                                                                                                                            Or                      ($___________ per person and $____________ each accident.)
                 Property Damage: ($_______________)

16. Is this an assigned risk policy?                                                                  Yes       □ No□
                                                                                                                                ▬ SEE CRITERIA ON BACK ▬
            I certify that the answers provided are true and correct to the best of my knowledge. I understand that in case of accident or claim, my
            insurance listed above provides my only coverage. In the event any of the above information changes, I will notify the school office

            Signature of driver______________________________________________________________                                                                                                                                                                                            Date____________________

            This application for the driver above has been:  Approved       Disapproved                                                         □                                                 □
            If disapproved, state reason:___________________________________________________________________________________

            The effective date of this application is today through     ___________________________________
                                                        (end of school year, expiration of insurance policy or driver’s license-whichever comes first).

            Signature of School Co-Director _____________________________________________________                                                                                                                                                                                            Date_______________________

              Distribution:                          (Original) Office Copy                                                                  Parent Driver Copy                                                                  Teacher Copy                                                      Sibling Teacher Copy

  These criteria are designed to assure school personnel and parents that children transported
  in private vehicles are transported safely in sound vehicles by competent, licensed drivers.

  Before private vehicles may be used, the driver of each vehicle to be used must complete and
  sign the Private Transportation and return it to the school. The school co-director will
  evaluate the answers provided by prospective drivers and sign the form indicating his/her
  approval of the volunteer driver. The driver will then receive a copy of the application. The
  approved driver is authorized to transport students only in the vehicle indicated on the

     The school co-directors shall DENY the authorization to drive and transport pupils to
     any person who:

      1. Does not possess a valid California driver’s license.

      2. Does not have automobile liability insurance with the following MINIMUN limits:
          Bodily Injury: Combined single limit of $300,000 or
                         $100,000 each person, and $300,000 each accident.

          Property Damage: $25,000

      3. Is insured as an assigned risk.

      4. Takes medication or has a physical condition that would affect driving safety.

      5. Is under 18 years of age.

      6. Has had an accident or moving violation within the past year.

      7. Does not have one (1) set of working seat belts per occupant.

      8. Is operating a vehicle with a known mechanical or safety defect.

IMPORTANT: In no instance shall a private vehicle be permitted to transport more than ten
(10) passengers including the driver, or no more than one (1) handicapped person confined to a
wheelchair, or the number of persons for which the vehicle is designed (Education Code Section
39830, Vehicle Code Section 545).

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